Chantal Birman

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    Psychological aspects of second trimester abortions for medical indications

    Chantal Birman (F)

     

     

    The Midwife’s Role in Helping Parents Through a Termination of Pregnancy

    Before dealing with the subject proper, I feel I should describe briefly the situation in France.

    Ultrasound was introduced in 1974. Early in the eighties the complete system for prenatal diagnosis was put in place. Over the same period, we learned how to extend the term of pathological pregnancies. Concurrently, progress in the management of prematurity helped these neonates to survive.

    Currently, fewer than 20% of terminations are performed under the provisions of the 1975 Act that allows such procedures where the mother’s health is at risk. Some 80% are carried out for foetal indications. Indications for terminations on medical grounds involve 1% of all births. The number of such terminations due to foetal abnormalities went from 1 in 400 births en 1981/83 to 1% in 1989/90. Down’s syndrome represents 50% of all anomalies found and 90% of these pregnancies are terminated. However, 30% of abnormalities escape antepartum detection (references: « Faire vivre et laisser mourir » by Dominique Memmi who recompiled data taken from the degree in social anthropology done by M. Piejus).

    The reason I have given these figures is to show that we midwives, whose role is to see mothers through their confinement, are confronted regularly, though not daily, with terminations of pregnancies for medical reasons.

    Over one year, these terminations involve few tours of duty and, for me, seldom number more than 5. At the Maternité des Lilas, where I work, two midwives are on duty and I always volunteer unless my colleague has managed the woman before I begin my shift. The terminations are performed in the delivery room, between normal births.

    It has been my experience that the vast majority of these procedures are done in the second three months of the pregnancy, rarely in the last three months.

    In France, we induce labour by the well-known Mifegine/Misoprostol[2] protocol. Analgesia is induced in two phases:

    1° Fentanyl perfusion with the flow rate adjusted to the requirement of the woman;

     2° epidural analgesia when required.

    It should be noted that conversely to the appeals of their partners and the opinions of the medical team, most women (of course not all of them) are less inclined to ask for immediate pain relief. For some of them, pain is a physical support for their intangible – because incomprehensible –torment caused by the anomaly.

    We midwives also are reminded by the painful contractions that this child, just like those of the other women giving birth, has become incarnate within this body and will soon be born dead or alive.

    While French legislation allows terminations on medical grounds, it outlaws infanticide. Application varies from one facility to another.

    The couple will not get the child of their dreams.

    The couple give birth to a dead baby.

    But the thing is that this child is abnormal; that is, a monster. Remember that monster derives from the Latin [from Old French monstre, from Latin monstrum (portent), from mon‘re (to warn)] and the term conveys at once the idea of foreboding and demonstrating or showing. Indeed the anomaly is only realised once it is revealed by the scrutiny of the ultrasonographer or the geneticist.

    The parents break both their lineages of normal children and register forever the anomaly in both families. Through this deed, for which they are not responsible, they actualise their monstrous parenthood and can bestow affection on the child they have borne.

    The voice of the midwife points out that the woman giving birth in the next room to a normal baby cannot be blamed for that normality. The voids between us are made of all these unanswered questions, and the unwinnable revolt against utterly unjust circumstance.

    Right then, the parents also want to vanish with their baby; yet they already know full well that the time afterwards is to come, that in it they will be survivors, and that life goes on.

    You have to be mad to go through pregnancy terminations however much - or little - involved you may be. For my part, I feel that the most fragile, because at once the most vulnerable, without being able to incorporate his grief is the father. It takes modesty to help him through. Often, I try to come to their aid through their wives, explaining to the women what is about to happen. In fact, the women have an inkling of what is to come; but not the men. Such indirect assistance helps the father realise that there are limits and that the madness in which he is entangled will come to an end.

    Strangely, the process of cervical dilation mimics the abnormality. Instead of being steady and predictable, as with the delivery of a normal child, the cervix remains hard, almost entirely effaced, only just patent, with a presentation bulging behind it. Suddenly, and quite unpredictably, the cervix opens and the foetus proceeds into the vagina, or is even expelled.

    Often, to shield the woman from the sounds of neighbouring births, her transfer to the delivery room is delayed. Hence, so that they will know what to expect, the couple must be informed that the birth may occur in the patient’s room. Quiet, cool-headed efficiency of the team appears to be the prime requirement to ensure the smooth progress, both technical and psychological, of these births.

     If necessary, once the foetus is born there is time to take the woman to the delivery room, for the placental birth and a uterine exploration. However, expulsion of the foetus on the stretcher is always upsetting to both parents and care providers.

    In conclusion, to help people through a termination of pregnancy is to weave mortality with monstrosity. This takes us to the borderline of humanity. You don’t know whether you come through it a better person or a destroyed one. One thing is sure: afterwards, it’s my skin (organ delineating the inside from the outside) that I determinedly scrub under the shower. I have long kept quiet about this cleansing, that I believed private; but my colleagues also feel this need. Now I know why that ablution belongs in traditional and religious rituals surrounding death.


     

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    “Should the women feel pain?”
    Chantal Birman, Midwife, Maternité des Lilas, Paris, France
    These thoughts arose from a comment made by a social worker remarking the high
    number of repeat abortions among women who had been victims of incest during their
    childhood. Undoubtedly, these women are hoping to heal their trauma by taking a
    pregnancy to term. However, such hopes are dashed and subsequent pregnancies follow
    on quickly, all ending in a termination. Colleagues working in maternity shelters noticed in
    these cases that
    (a) talk about contraceptives was totally ineffective, and
    (b) the relationship between the life experience of these women, with all the perversions it
    may entail, and the gynaecological and obstetric events they have passed through was, in
    their eyes, obvious!
    This is what I want to summarize in my title: what is the value of a woman’s blood? What
    does she pay for with her blood?